1. A nurse manager is preparing to institute a new system for scheduling staff. Severalnurses have verbalized their concern over the possible changes that ... [Show More] will occur. Which of the following is an appropriate method to facilitate the adoption of the new schedulingsystem?
A. Identify nurses who accept the change to help influence other staffnurses
B. Provide a brief overview of the new scheduling system immediately beforeit implementation
C. Introduce the new scheduling system by describing how it will save the institutionmoney
D. Offer to reassign staff who do not support the change to anotherunit
2. A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the carepathway?
A. Antibiotic therapy was initiated 2 hr after implementation of the carepathway
B. A blood culture was obtained after antibiotic therapy has beeninitiated
C. The route of antibiotic therapy on the care pathway was changed from IV toPO
D. An allergy to penicillin required an alternative antibiotic to beprescribed.
3. A nurse should recognize that an incident report is requiredwhen
A. A client refuses to attend physicaltherapy
B. A visitor pinches his finger in the client‟s bedframe
C. A client throws a box of tissues at anurse
D. A nurse gives a med 30 min late
5. Client satisfactory surveys from a med-surg unit indicate the pain is not being adequately relieved during the first 12 hr post-opt. The unit manager decides to identify post-opt pain as a quality indicator. Which of the following data sources will be helpful in determine the reason why clients are not receiving adequate pain management aftersurgery?
A. Prospective chartaudit
B. Retrospective chartaudit
C. Postoperative carepolicy
D. Pain assessmentpolicy
6. A nurse precepting a newly licenced nurse who is caring for a client who is confused and has an IV infusion. The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter. Which of the following questions should the precepting nurseask?
A. “Did you secure the restraints to the side rails of thebed?”
B. “Are you able to insert two fingers between the restraint and the client‟sskin?”
C. “Did you tie the restraints using doubleknot?”
D. “Are you removing the client‟s restraints every 4hr?”
7. A nurse is caring for an older adult client who has stage III pressure ulcer. The nurse requesta consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with aconsultant?
A. Arrange the consultation for time when the nurse is caring for the client is able to be present forconsultation
B. Provide the consultant with subjective opinions and beliefs about the client‟s woundcare
C. Request the consultation after several wound care treatmenttried
D. Arrange for the wound care nurse specialist to see the client daily to provide the recommendedtreatment
8. A client is admitted wit TB and placed in a negative pressure room. Which of thefollowing actions isappropriate?
A. Notify the local health department of theadmission
B. Place a sign on the client‟s door with thediagnosis
C. Ensure that admitting staff undergo PPD skintests
D. Determine who had contact with the client in the last 48hr
9. A nurse is caring for a client who is unconscious and whose partner is health care proxy. The partner has spoken with the provider and wishes to discontinue the client‟s feeding tube. The providerstatesthenurse,“Iwillnotdiscontinuetheclient‟streatment.Hispartnerhasnorightto make decisions regarding the client‟s care. “Which of the following responses by the nurse is appropriate?
A. Youshouldconsiderspeakingwiththefacility‟sethicscommitteebeforemakingyour decision
B. You have the right to make decision, even if the partner is the client‟s health careproxy
C. The client has designated his partner as health care proxy in his advancedirectives
D. We‟ll need to have the nursing supervisor review the client‟s advancedirectives
10. A nurse is caring for a client who has increased intracranial pressure and is receivingIV corticosteroids. Which of the following info is most important for the nurse to report at shift change?
A. Gasglow Coma scalescore
B. Most recent blood glucose reading
C. Lab test scheduled for nextshift
D. Reddened area on thecoccyx
11. A nurse is assigned the following four clients for the current shift. Which of the following clients should the nurse assessfirst?
A. A client who has a hip fracture and is in Buck‟straction
B. A client who has aspiration pneumonia and a respiratory rate of28/min
C. A client who has diabetes mellitus stage 2 pressure ulcer on hisfoot
D. A client who has a C diff infection and needs a stool specimencollected
12. A nurse is caring for a client who fell and is reporting pain in the left hip with external rotation of the left leg. The nurse has been unable to reach the provider despite several attempts over the past 30 min. Which of the following actions should the nursetake?
A. Notify the nursing supervisor about theissues
B. Contact the client‟s physicaltherapist
C. Apply a warm compress to thehip
D. Reposition the client forcomfort
13. The mother of a client with breast cancer states, it‟s been hard for her, especially afterlosing her hair. And it has been difficult to pay for all the treatments. Which of the following actions is appropriate clientadvocacy?
A. The nurse investigates potential resources to help the client purchasewig
B. The nurse explains to the mother that most clients with cancer lose theirhair
C. The nurse informs the next shift nurse regarding the mother‟sconcerns.
D. The nurse suggests counseling for the client‟s body imageissues
14. Which of the following items must be discarded in a biohazard wastereceptacle?
A. A urinary catheter drainage bag from a client who ispost-opt
B. A bed sheet from a client with bacterialpneumonia
C. A perineal pad from a client who is 24-hr post-vaginaldelivery
D. An empty IV bag removed from a client who hasHIV
15. A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don‟tget better, I‟m going to quit. “Which of the following responsesappropriate?
A. “So you are upset about all the changes on theUnit”
B. “I think you have a right to be upset, I am tired of the changestoo”
C. “Just stick with it a little longer. Things will get bettersoon
D. “ You should file complaints with hospitaladministrator
16. According to the HIPAA regulations, which of the following is a violation ofclient confidentiality?
A. Telephone the pharmacy with a prescription for the spouse to pickup
B. Providing a copy of the record to the transportingparamedic
C. Reporting a client‟s disposition to the referringprovider
D. Informing housekeeping staff that the client is in dialysisunit
17. ANursepreceptorisevaluatinganewlylicensednurse‟scompetencyinassistingwitha sterile procedure. Which of the following actions indicates the nurse is maintaining sterile technique? (Select all thatapply.)
A. Open the sterile pack by first unfolding the flap farthest from herbody
B. Rests the cap of a solution container upside down on the sterilefield
C. Removes the outside packaging of a sterile instrument before dropping into thesterile
D. Holds a bottle of a sterile solution 15 cm (6 inches) above the sterilefield
E. Places sterile items within 1.25 cm (0.5 inch) border around the edge of the sterilefield
18. A nurse is providing care for 4 post-opt clients. The nurse should first assess theclient
A. Whose pulse has been steadily increasing during the pastshift
B. Who is reporting a pain level of 8 on a scale of 0 to10.
C. Whose urine output averaged 32 ml/hr for the past 24hr
D. Who is reporting nausea after the prescribed antiemetic wasadministered
19. A nurse is preparing to transcribe a client‟s med prescription in the medical record. Whichof the following should the nurse recognize as containing the essential components of a medication order?
A. NPH insulin 10 Units before and atbedtime
B. Haloperidol (Hadol) 1mg permouth
C. Multivit every morning bymouth
D. Aspirin 650 mg by mouth every4hr
20. A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which ofthe following interventions isappropriate?
A. Recommend that he takes time to plan at the beginning ofshift
B. Advise him to complete less time-consuming tasksfirst
C. Ask other staff members to take over some of hisstaffs
D. Offer to provide care for his clients while he takes abreak
21. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting, which of the following actions should the nurse takefirst?
A. Remove the client‟sclothing
B. Irrigate the exposed area withwater
C. Report the incident toOSHA
Don personal protective equipment.
22. A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors isobserved?
A. A nurse refuses to actively participate during an elective abortion procedurescheduled for herclient.
B. A nurse gives prescribed opioids to a client who has a terminal illness and respirationsof 8/min
C. A nurse explains to a client‟s family that a DNR order includes withholdingcomfort
D. A nurse informs a confused client who wants to go home that he is going to stay atthe facility until he isbetter
23. A nurse is an ambulatory care setting is orienting a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth?
A. Assessing clientneeds
B. Providing medreconciliation
C. Establishing communication betweenproviders
D. Developing client treatmentprotocols
24. Which of the following put a hospital at the highest risk of infringement of clientrecord confidentiality?
A. A nurse clusters documentation of care for multipleclients?
B. A provider and nurse access client info using one accesscode
C. Paper-based charts are stored at the nurse‟sstation
D. A nurse performs electronic documentation outside a client‟sroom
25. Which of the following observations requires a charge nurse to intervene anddemonstrate safe handlingtechniques?
A. A nurse cleans up blood spill with a 1:10 bleachsolution
B. A nurse uses googles to perform tracheostomysuctioning
C. A nurse disconnects an indwelling urinary catheter from the drainage bag to collecta
D. A nurse places a mask on a client with TB before transport to the radiologydepartment
26. Which of the following should lead a nurse to suspect abuse that must bereported?
A. A school-age child has several bruises on her lowerlegs.
B. A toddler cries whenever his parents enters the hospitalsroom.
C. An Adolescent admitted to the emergency won‟t speak to hisparents
D. A preschool child who was previously toilet trained now requires diapers in thehospital
27. A parish nurse is making referral to a community meal delivery program for a member of the congregation. This is an example of which of the following functions of the parishnurse?
B. Pastoral careprovider
C. Health educator
D. Personal Healthcounselor
28. A nurse performing triage during a mass casualty incident should recognize that which ofthe following clients should be transported to the hospitalfirst?
A. A client who reports substernal chest pain radiating to the neck?????
B. A client who has an open fracture of thefemur
C. A client who has a 4-inch laceration on theforearm
D. A client who has a penetrating head injury and fixed dilatedpupils
30. A nurse manager overhears a provider and a staff nurse talking about a client‟s diagnosisin the cafeteria. Which of the following actions should the nurse takefirst?
A. Provide a staff in-service about clientconfidentiality
B. Report the incident to the nursingsupervisor
C. Remind them that the client info is confidential????????
D. Fill out an incident report regarding thesituation
31. A client has a substance use disorder is admitted to the mental health Unit and reports that he has been depressed lately. When preparing for discharge the next day, the client states: “It‟s Ok. Soon everything will be just fine.” Which of the following is the nurse‟s primary firstaction?
A. Ask the client if he has considered hurting himself
B. Provide the client with info about AlcoholicsAnonymous
C. Encourage the client to participate in physicalactivities
D. Reinforce the need to follow up with the dischargereferral
32. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administer the injection. This illustrate which of thefollowing?
33. A nurse manager smells alcohol on the breath of a nurse who is starting a shift. Which of the following actions should the nurse manager takefirst?
A. Report the situation to the director ofnursing
B. Have a blood alcohol level drawn from thenurse
C. Document a factual description of thesituation
D. Remove the nurse from theunit
34. A nurse observes a paper bag at the bedside of a client. This finding suggest that the clientis receiving treatment for which of the respiratorydisorders
35. A nurse is preparing the discharge a client back to a long-term care facility after he was admitted to an acute care facility 2 days ago for pneumonia. Which of the followinginformation should the nurse include in the verbal transferreport?
A. Lab results within the expected referencerange
B. List of regularly prescribedmeds
C. Date of last bowelmovement
D. Level ofconsciousness
36. A nurse who is precepting a newly licensed nurse is discussing the client assignment for the shift. Which of the following actions should the nurse preceptor take first to demonstrate appropriate timemanagement?
A. Review the client‟s new labvalues
B. Document assessmentdata
C. Complete requiredtasks
D. Determine client caregoals
37. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which ofthe following statements by the newly licensed indicates understanding of isolationguidelines?
A. I will instruct visitors to wear a mask when visiting a client who is on contactprecaution
B. I will place a client who has compromised immunity in a negative-pressure airflowroom
C. I will wear N-95respirator mask when caring for a client who is on dropletprecaution
D. I will have a client who is on airborne precautions wear a mask when out of herroom
38. A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is appropriate to delegate to a licensed practicalnurse?
A. Changing the dressing on a postoperativewound
B. Referring a client to social services for assistance withtransportation
C. Instructing a client who is obese about a low-fatdiet
D. Providing the first oral feeding to a client following astroke
39. A case manager working in a rehabilitation unit is discharging to home a client who aspinal cord injury level C-7. Which of the following is the priority action creating the dischargeplan?
A. Select strategies for cost-effective homecare
B. Identify the client‟s ability to perform activities of dailyliving
C. Provide educational handouts related to carerequirements.
D. Recommend community resources available to assist with clientcare.
40. A nurse is preparing to complete morning assessments on several assigned clients. Whichof the following clients should the nurse plan to assessfirst?
A. A client who has a nasogastric tube to intermittent suction and reportsnausea
B. A client who has an early morning blood glucose of 220mg/dl
C. A client who had a bladder scan that indicated 250 ml of urine in thebladder
D. A client who is 3 days post-opt & whose dressing has serosanguinousdrainage
41. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practicalnurse?
A. Plan break times for assistive personnel.
B. Pick up the meal trays afterlunch.
C. Administer a nasogastric tubefeeding.
D. Determine adequacy of ventilatorsettings
42. An RN is planning client assignments for a licensed practical nurse (LPN) and threeassistive personnel. The RN should assign the LPN to the client whorequires
A. Recording of daily intake andoutput
B. Assistance withmeals
C. A complete bedbath
D. Frequent dressingchanges
44. A nurse is caring for 4 clients. Which of the following tasks can be delegated to an assistive personnel?
A. Assessing a client who just returned fromhemodialysis
B. Reviewing dietary instructions for a client with kidneystones
C. Obtaining a stool sample from a client with renalfailure
D. Monitoring a client with a fluidrestriction
45. A charge nurse is making rounds observes that an assistive personnel (AP) has appliedwrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse takefirst?
A. Inform the unit manager of theincident
B. Remove the restraints from the client‟swrists.
C. Speak with the AP about theincident
D. Review the chart for non-restraint alternatives foragitation.
46. A client is brought to the emergency department (ED) following a motor-vehiclecreash.
Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse?
A. Document the client‟s refusal in thechart
B. Tell the client that a catheter will beinserted
C. Obtain a provider‟s prescription for a blood alcohollevel.
D. Assess the client for urinaryretention.
47. Nurses on an impatient care unit are working to help reduce unit costs. Which ofthe following is appropriate to include in the cost-containmentplan?
A. Use clean gloves rather than sterile gloves for colostomycare.
B. Wait to dispose of sharps containers until they are completelyfull.
C. Return unused supplies from the bedside to the unit‟s supplystock.
D. Store opened bottles of normal saline in a refrigerator for up to 48hr.
48. An older adult client is awaiting surgery for a fractured right hip. The nurse shouldrecognize that which of the following can be delegated to an assistive personnel?
A. Turning theclient
B. Recording the client‟s vitalsigns
C. Determining the client‟s painlevel
D. Checking the pulses of the client‟s rightfoot.
49. To resolve a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict-resolution strategies in the nursemanager using?
50. A charge nurse on an obstetrical unit is preparing the shift assignment. Which ofthe following clients should be assigned to an RN who has floated from a med-surgunit?
A. A client who has gestational diabetes and is receiving biweekly nonstresstests
B. A primigravida client who is 1 day post-opt following a cesarean section and has aPCA pump
C. A multigravida client who has preemclampsia and is receiving mistoprostol (Cytotec)for induction of labor.
D. A client who is at 32 weeks of gestation and has premature rupture ofmembranes.
51. A nurse working on a med-surg unit is managing the care of 4 clients. The nurse should schedule an interdisciplinary conference for which of the followingclients?
A. A client who is at risk for pressure ulcers and has an albumin of 4.2g/dl
B. A client who has type 1 DM and uses insulinpump
C. A client who has orthostatic hypotension and is receiving IVfluids.
D. A client who is receiving heparin and has an aPTT of 34seconds
52. A charge nurse is assessing staff knowledge about safety procedures regarding needlestick injuries. Which of the following statements by a nurse indicates appropriate understanding of these safetyprocedures?
A. Prophylatic treatment should be initiated after a needlestick during preparation ofan injection
B. I should stop the bleeding as soon as possible following a needlestickinjury
C. An incident report should be completed if a client receives a stick from her ownused needle
D. The needle should be recapped to prevent injury during transport to thebiohazard container.
53. A nurse on a medical surg Unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and an assistive personnel. Which of the following taks shouldthe nurse assign to theLPN
A. Obtaining a urine specimen from an older adultclient
B. Providing postmortem care for a client who has justdied
C. Accompanying a client who just had a wound debridement to physicaltherapy
D. Reinforcing dietary teaching with a client who has heartdisease
54. A nurse enters the room of a client who is unconscious and finds that the client‟s sonis reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse takefirst?
A. Recommend the son meet with the provider to get info about his mother‟scondition
B. Complete an incident report regarding the breach of the client‟sconfidentiality
C. Log out of the computer so that the client‟s son is unable to view his mother‟sinfo
D. Report the possible violation of client confidentiality to the nursemanager
55. A home health nurse is assessing the home environment of a client who is oncontinuous oxygen therapy. Which of the following findings requires the nurse tointervene?
A. The oxygen machine has a grounded plug?????????
B. The family keeps a spare oxygen tank in theroom
C. The window of the client‟s room areopen
D. The client is covered with a woolenblanket
Rationale: Oxygen therapy safety precaution: Avoid materials that generate static electricity, such as woolen blankets and synthetic fabrics. Advise clients and caregivers to wear cotton fabrics and use cotton blankets.
56. A nurse is teaching a client how to use a finger stick glucometer at home. Which of the following instruction should the nurseinclude?
A. Elevate the arm for 1 min before taking the bloodsample
B. Cap the lancet prior to putting it in in thetrash
C. Obtain the blood sample from the fingerpads.
D. Warm the hands prior to piercing theskin
57. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of thefollowing actions should the nursetake?
A. Contact the client‟s next of kin to obtain consent fortreatment.
B. Proceed with treatment without obtaining writtenconsent
C. Have the client sign a consent fortreatment.
D. Notify risk management before initiatingtreatment.
58. A client has a new permanent pacemaker inserted. Which of the following homecare instructions should the nurseinclude?
A. The client should avoid using microwave oven to heat food????????
B. Regular programming evaluations can be conducted bytelephones
C. The client should avoid using remote control devices to preventdysrhythmias
D. Suctioning could cause the unit to have an electricalshock.
59. While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that 6 of the 15 records lack documentation regarding advance directives.Which of the following is the priority action for the nurse totake?
A. Reinforce the potential consequences of not having this info on record to the nursing staff.
B. Ask the nurses who are caring for clients without this info in the medical record toobtain
C. Meet with nursing staff to review the policy regarding advancedirectives.
D. Remind nurses to obtain this info during the admissionprocess.
60. A client is admitted with COPD. Which of the following findings should the nurse reportto the provider?
A. Oxygen saturation 89% on roomair.
B. WBC‟s count9,000/mm
C. Report of dyspnea onexertion
D. Bilateral crackles on auscultation oflungs.
61. A charge nurse notices 2 staff nurses are not taking meal breaks during 8-hr shifts. Which of the following actions should the nurse takefirst?
A. Provide coverage for the nurse‟sbreaks.
B. Determine the reasons the nurses are not taking scheduledbreaks.
C. Discuss tie management strategies with thenurses.
D. Review facility policies for taking scheduledbreaks.
62. A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client‟s care? (Select allthat apply.)
D. Mental Healthcounselor
E. Case manager
63. A nurse manger is reviewing guidelines for informed consent with the nursing staff.Which of the following statements by a staff nurse indicates that the teaching waseffective?
A. Guardian consent is required for an emancipatedminor
B. Consent can be given by a durable power ofattorney.
C. A family member can answer any questions the client has about theprocedure.
D. The nurse can answer any questions the client has about theprocedure
64. A nurse on a medical-surg unit is caring for 4 clients. This nurse should recognize that which of the following clients is the highestpriority?
A. A client who is newly diagnosed with pancreatic cancer and is scheduled to beginIV chemotherapy.
B. A client who has peripheral vascular disease and has absent pedal pulse in rightfoot.
C. A client who is post-opt following a laminectomy 12 hr ago and is unable tovoid.
D. A client who has methicillin-resistant Staphylococcus Aureus (MRSA) and has an axillary temp of 38 degree C ( 101F)
65. A client scheduled for a tubal ligation procedure starts to cry as she wheeled into thesurgical suite. Which of the following nursing statements is an appropriate nursingresponse?
A. It‟s not too late to cancel the surgery if you wantto
B. This won‟t take long and it will be over before you knowit.
C. Why did you make the decision to have thisprocedure
D. You shouldn‟t be worried because the procedure is verysafe
66. A nurse working in the emergency department is assessing several clients. Which of the following clients is the highestpriority?
A. A client who has a raised red skin rash on his arms, neck, andface
B. A client who reports right-sided flank pain and isdiaphoretic
C. A client who reports shortness of breath and left neck and shoulderpain
D. A client who has active bleeding from a puncture wound of the leftgroin
67. A nurse is working on a quality improvement team that is assessing an increase in clientfalls at the facility. After problem identification, which of the following actions should the nurse plan totake first of the quality improvementprocess?
A. Review current literature regarding clientfalls.
B. Implement a fall preventionplan
C. Notify staff of the increased fallrates
D. Identify clients who are at risk forfalls
68. A nurse is evaluating a newly licensed nurse who is administering a vitamin K (Aquamephytoin) injection to a newborn. Which of the following actions by the newlylicensed nurse indicates understanding of the teaching? (Select all thatapply.)
A. Selects the dorsogluteal site to administer theinjection
B. Cleans the injection site withalcohol
C. Applies gentle pressure at the site afterinjection
D. Aspirate the syringe for blood return after needleinsertion
E. Inserts the needle at a 45 degreeangle.
69. A nurse enters a client‟s room and observes a fire in a trash can. Identitfy, the sequenceof actions the nurse should take. ( Move all the actions into the box on the right, placing themin the selected orderperformance.)
1. Remove the client from thearea
2. Activate the fire alarmsystem
3. Confine the fire by closing doors andwindows
4. Extinguish the fire ifpossible
70. Which of the following actions taken by a nurse constitutesbattery?
A. Failing to put up side rails on a confused client‟sbed
B. Telling a client who refused his oral medication that he will be given aninjection C. Inserting a feeding tube against the wishes of a client who refuses toeat
D. Threatening to apply wrist restraints to control a client who isagitated [Show Less]